But Medicare claims analysis shows state-by-state use varies widely

Action Points

Telemedicine to deliver mental health services in underserved, rural areas of the U.S. has risen dramatically in recent years according to Medicare fee-for-service claims, but state-to-state regulations vary, and distribution remains uneven.

Note that only a small percentage of patients with mental illnesses receive treatment, with the lack of mental health specialists in rural areas recognized as a key barrier to therapy.

The use of telemedicine to deliver mental health services in underserved, rural areas of the U.S. has risen dramatically in recent years, but state-to-state distribution remains uneven, researchers reported.

An analysis of nationwide Medicare fee-for-service claims between 2004 and 2014 showed an average annual 45% increase in telemedicine single visits among rural patients, with dramatic variations across states.

In 2014, there were more than 25 telemedicine visits per 100 patients with serious mental illnesses in nine states, while four states and the District of Columbia had none, researcher Ateev Mehrotra, MD, of Harvard Medical School, and colleagues, wrote in the May issue of the journal Health Affairs.

Overall, just 1.5% of patients with serious mental health disorders living in rural areas received treatment via telemedicine.

"People ask me if this report is good news or bad news, since telemedicine is being used in just over 1% of patients, and in a lot of states it is closer to 0%," Mehrotra told MedPage Today. "But I'm probably in the 'good news' camp, because nationwide close to 100,000 mental health visits happened in 2014."

The researchers noted that only a small percentage of patients with mental illnesses receive treatment, with the lack of mental health specialists in rural areas recognized as a key barrier to therapy.

Telemedicine has been widely promoted as a way to eliminate barriers to treatment for patients without access to specialists, but the extent of its use nationwide has not been previously studied, Mehrotra said.

The researchers examined Medicare beneficiaries with a mental illness diagnosis to help inform the ongoing debate among federal, state, and local lawmakers about the value of expanding telemedicine coverage.

"Medicare has taken a cautious approach to reimbursement for telemedicine," they wrote. "Current Medicare regulations provide coverage only for those living in rural areas, and they mandate that the interaction occur via live video conference. In addition, the patient must be housed at a clinic or facility such as a hospital in a rural region, and not be at home or the workplace."

In the newly published study, the researchers focused on rural Medicare beneficiaries diagnosed with any mental illness and those diagnosed with serious mental illnesses, such as bipolar disorder and schizophrenia.

A total of 14.5% of rural Medicare beneficiaries had a mental health diagnosis in 2014 and 3.7% had a diagnosis of a serious mental illness.

Between 2004 and 2014:

The number of telemental health visits among rural patients with any mental illness rose from 2,365 to 87,120 visits, for an average annual growth rate of 45.1%.

The number of visits among those with serious mental illness rose from 1,040 to 50,050 (an average annual growth rate of 49.3%).

Nevada and Wyoming had the largest per-capita number of visits, with 45 visits per 100 beneficiaries in 2014, and Arizona, Colorado, Nebraska, Iowa and North Dakota were among the states with at least 30 visits per 100 beneficiaries.

While usage was somewhat greater in states with telemedicine parity laws addressing reimbursement for telemental health services, the rate of growth in states with and without such laws was similar, Mehrotra told MedPage Today.

He said a much bigger driver of telemedicine use was the regulatory climate.

"It is a crazy landscape out there at the moment with regard to state-by-state regulation of telemedicine," he said. "Some states require in-person visits before telemental health services are allowed, some require a formal protocol for addressing patients who may be suicidal, and there are all kinds of other differences."

The researchers noted that there is ongoing debate in Congress about the value of expanding telemedicine coverage for Medicare beneficiaries. The Congressional Budget Office has called for more research to better understand the impact of loosening restrictions on telemedicine, such as allowing services to be provided in patients' homes or eliminating the need for treating clinicians to be licensed in the state where the patient lives.

"Such changes would certainly increase the use of telemental health," the researchers wrote. "However, there is concern that such an expansion could result in the overuse of telemedicine services which would add to healthcare costs without providing compelling clinical benefits."

Funding for this research was provided by the Melvin Hall and CHSi Corporation.

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